Leading Better Value Care
Local vignette – Central Coast LHD

Osteoporotic re-fracture prevention

Multidisciplinary shared care model – a clinician's perspective

By Kelly Armstrong

27 Apr 2021 Reading time approximately

What is important to know about your service?

The Osteoporosis Re-fracture Prevention (ORP) service is located at the Wyong Central Community Health Centre for patients at the northern end of the Central Coast; the Woy Woy Community Rehabilitation Centre is utilised for patients at the southern end of the Central Coast. Both locations are accessible via public transport and there is free parking at the door. The service operates Monday to Friday, 8:00am to 4:30pm and is eligible for people aged 50-75 years who present to Wyong and Gosford hospital emergency departments with a minimal trauma fracture.

What organisational model do you use?

Multidisciplinary shared care model.

Identification and triage
leads to
Assessment and diagnosis
leads to
Treatment initiation
leads to
Coordination of ongoing care

What is special about the way care is delivered that is valuable for others to know?

The ORP service provides a comprehensive person-centred assessment, care coordination, bone health education and self-management support.

Patients presenting to the emergency department with a minimal trauma fracture are identified through a weekly generated report and screened utilising an eligibility criteria. The fracture liaison coordinator reviews each patient’s emergency assessment past history and discharge summary to determine their suitability to attend the service.

Eligible patients are called and offered an appointment within 14 days. A comprehensive assessment including fracture history, medical history, lifestyle factors, falls history, social needs and co-morbidities is completed. A physiotherapist also conducts a comprehensive assessment including falls assessment using the Berg Balance test, sit to stand and falls self-efficacy tool.

The fracture liaison coordinator arranges the consultation with a specialist endocrinologist (usually within three months), including referral from the general practitioner. There are standing orders for bone mineral density, thoracic/lumbar X-ray and pathology. Referrals can also be made to other services including falls prevention programs, physiotherapy, occupational therapy, Get Healthy service, drug and alcohol services.

If patients are commenced on medication they have a 12 month follow up with the endocrinologist. The fracture liaison coordinator follows up patients via phone at three, six and 12 months.

A companion document describes options for organisational models in osteoporotic refracture prevention. One option is a multidisciplinary shared care model – this vignette describes the model from a local perspective

How does it make a difference?

The fracture liaison coordinator, physiotherapists and endocrinologists’ case manage patients for optimal care of their bone health, falls prevention and re-fracture prevention.  ORP is also creating awareness about osteoporosis, falls prevention and the importance of bone health to the community at large.

What tips do you have for others?

  • Accessible ORP service locations are key. Consider ease of parking and public transport.
  • Facilitate education on bone health and falls prevention to the wider community.

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